12080063 CITY OF CUPERTINO 13UILDING PERMIT
BUILDING ADDRIiSS: 10057 SPANISIi OAK C'I' CON'TRACT'OR:PETERSEN-DEAN INC 1'ERMITNO: 12080063
O\YNISR'SNAME: SINGI.E'I'ONRICIIARDCANDI'RANCI 7980 ENTERPRISE DR DATE ISSUED:08/072012
O\\'NER'SMIONF-: 6509409220 NE\YARK.CA 94560 PHOS:NO:(5tl)t94-9982
❑ LICENSED CO\TRACT'OR'S DECLARATION BUILDING PERDI IT INFO: BLDG r ELECT r PLUMB r
License Class Lie.N
p1ECF1 r RESIDENTIAL r COMMERCIAL -
Contractor Date
hereby affirm that I am licensed under The provisions of Chapter 9 -JOB DESCRIPTION: REMOVE SI[AKE ROOF INSATALL PRESIDENTIAL TL
(commencing with Section 7000)of Division 3 of The Business& Professions SHINGLES OVER 30k FELTAND COX SHEATIJING-1ISQFT
Code and that my license is in full force and effect.
I hereby affirm tinder penalty of perjury one of the following two declarations:
I have and will maintain a cenificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Fluor Area:0 Valuation:$6000
Section 3700 of the Labor Code,for the performm�ce of the work for which this
permit is issued. -
APNNumber:34232086.00 Occupamcy'I'ype:
,u'rLlc,w'r r_ER'rurlCYr10N
I certify that I have read this application and state than the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction.and hereby authorize representatives ofthis city to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indenmify and keep harmless the City ol'Cupenino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR r
costs,and expenses which may accmc against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Issued by: Date:
Signature Date
❑ OWNER-11-Ul LDI.R DECLARATION' RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed If a roof is
1 hereby affirm that 1 am exempt from the Conlranor's License Lmv for one of installed without first obtaining an inspection.I agree to remove all nest'materials for
the following taro reasons: inspection.
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: Date:
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BE PIER
J hereby affirm under penally of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent m self-insure for Worker's I have read the hazardous materials requirements ander Chapter 6.95 of the
Compensation,as provided for by Section 3700 ofthe Labor Code,for the California Ilealth&Safety Coda Sections 25505.25533.and 25534. 1 will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Ilcalth&
I have and will maintain Worker's Compensation Insurance,as provided Ion by Safety.Code,Section 25532pq should 1 store or handle hazardous material.
Section 3700 of the Labor Code,I•or the performance ol'the work for which this Additionally.should I use equipment or devices which emit hazardous air
permit is issued.. contaminants as defined by the Bay Area Air Quality Management District J will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work I•or which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of Califo nia. If,after making this certificate of exemption,I Owner ar authorized agent:
become subject to the Worker's Compensation provisions of the Labor Code,I must Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
A 1'PIJC\\1'CF:RTI PIf.A'1'll l\ I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097.Civ Q
correct.I agree to comply with all city and county ordinances mid state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgnmcnts,
costs,and expenses which may accme against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply .\RcnrrF:crs DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date